Provider Demographics
NPI:1932281615
Name:TALLADEGA HEALTHCARE CENTER, INC.
Entity Type:Organization
Organization Name:TALLADEGA HEALTHCARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:MS
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-273-9002
Mailing Address - Street 1:616 CHAFFEE ST
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-2809
Mailing Address - Country:US
Mailing Address - Phone:256-362-4197
Mailing Address - Fax:256-362-0726
Practice Address - Street 1:616 CHAFFEE ST
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2809
Practice Address - Country:US
Practice Address - Phone:256-362-4197
Practice Address - Fax:256-362-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12681314000000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL47-50210SMedicaid
AL009936787Medicaid
AL009936787Medicaid
AL47-50210SMedicaid
015162Medicare Oscar/Certification